Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> ' See reverse side for instructions for completing this application PO Box 7302 <br /> 14sconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County y� State Sanitary P rmit N mber ❑Check if vision to previous a plication State Plan I.D.Number <br /> kj ce r 14 e -f FJ �S z) 63 17s,/v <br /> I.Application Information-Please Print all Information Location: <br /> Pro erty Owner <br /> Name [/ Property�Lojcaatti-on q cy r( <br /> ACL C� U e C f� w 1/4/"G1/4,SJ�T3/,N,R a}'•WF)R <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ca,+4Ae hi ii ss as ( 6b-7 ) 63-7.Z *m t)t, Ass. <br /> II.Type of Building: (check one) ❑City <br /> X 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> [3 Public/Commercial(describe use):_ (Town of <br /> ❑State-Owned h] exf N t7r <br /> earest5ti L—k I QLot" <br /> Parcel Tax Number(sb1 12.5 0-3 9Q0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. A Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground ,KMound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> Sao Sao 3c>/ 9sY, 3� SSI r3- <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> 000 -e <br /> C9 ❑ ❑ ❑ ❑ <br /> 00D ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibi Vty for installation of the POWTS shown on the attached plans. <br /> Plumber's NamtarnMP/MPRS No.e <br /> e �S intoe � r 7�Businc ss Phone Number <br /> Z22Zs iEra� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7o'> (,c� , Sb'�l3 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Pennigee(Includes Groundwater Date Igsued Issuing Age t nature p <br /> proved ❑Owner Given Initial Adverse Surcharge Fee ®, D <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: -7 <br /> SBD-6398(R.07/00) <br />